Men's engagement in maternal, newborn and child care : promoting health and gender equality

Executive summary (English) Women, newborns and children in low- and middle-income countries face an unfair and unacceptably high burden of poor health in pregnancy, during and after childbirth, and in the first five years of life. The burden of poor maternal, newborn and child health (MNCH) in low- and middle-income countries is largely preventable through high coverage of essential health services, combined with optimal caregiving and other health promoting behaviours. Gender inequality is a key driver of poor MNCH in low- and middle-income countries, and working with men as well as women has been recognised as a promising strategy to improve gendered MNCH outcomes. Some interventions to influence men’s engagement in MNCH have been demonstrated to increase uptake of essential MNCH services and improve the quality of caregiving and health promoting behaviours. Overall, however, the evidence base for this approach is patchy, and inconclusive. The aim of this thesis is to investigate how interventions designed to influence men’s engagement in MNCH can be made optimally effective for the health and wellbeing of women and children, particularly in low- and middle-income countries. This is addressed by, first, assessing the effectiveness of these interventions on MNCH outcomes, and then identifying key mechanisms through which the interventions achieve any observed positive effects. An exploratory sequential mixed-methods design is used to integrate findings from two evidence syntheses and two primary studies in an iterative, reflective process of hypothesis development. Findings across the four studies are integrated to propose a detailed hypothesis – a theory of change – for interventions designed to influence men’s engagement in MNCH. The first two papers submitted for this thesis report on a systematic review of the effectiveness of male involvement interventions for maternal and newborn health outcomes in low- and middleincome countries. The review identifies that these interventions can improve health service utilisation and home care practices, while at the same time finding variable intervention effects with some harmful outcomes (Chapter 4.1). Secondary content analysis of studies included in the systematic review (Chapter 4.2) applies a critical gender lens to explore how interventions engaging with men can support gender-transformative change and identify factors that may underpin the variable and harmful outcomes identified through the effectiveness review; this analysis identified lines of enquiry that were explored through subsequent primary studies and a global evidence synthesis. The third paper submitted for this thesis reports on a primary qualitative study exploring the experiences of men and women in Tanzania and Zimbabwe who had been exposed to interventions designed to influence men’s engagement in MNCH (Chapter 4.3). Study findings highlight the importance of increased love, happiness and emotional intimacy in coparent relationships, both as a wellbeing outcome valued by women and men, and as a contributor to the effectiveness of interventions engaging with men for MNCH. The fourth paper submitted for this thesis reports on a cluster-randomised controlled trial of a gendersynchronised intervention with women and men in rural Zimbabwe, which was designed to support men’s positive engagement in MNCH (Chapter 4.4). Trial results demonstrate that the intervention enhanced men’s practical support for women and infants, enabled coparents’ equitable, informed MNCH decision-making, and improved maternal mental health and MNCH care-seeking. The final paper submitted for this thesis presents the results of a global qualitative evidence synthesis of the experiences of women, men and health providers relating to interventions designed to influence men’s engagement in MNCH (Chapter 4.5). Findings indicate that interventions enable health service utilisation and improve the quality of care for women, newborns and men, and also strengthen family relationships. Synthesis findings also illustrate that poorly designed or implemented interventions can constrain some women’s access to health services and compound the negative impacts of existing gender inequalities. Finally, findings highlight the importance of context, including health system factors, gender norms, sociodemographic characteristics, and household needs, on intervention uptake and outcomes. Overall, thesis findings provide persuasive evidence that interventions to influence men’s engagement in MNCH can have substantial benefits for women’s, newborn’s and children’s health. Findings indicate key mechanisms through which interventions can improve MNCH: more loving and genderequal coparent relationships, men’s increased practical support for MNCH, and men’s improved health and wellbeing. Findings also highlight the influence of health system context and established and emerging gender norms, and the importance of considering these factors in intervention design and delivery. The proposed theory of change illustrates how interventions seeking to influence men’s engagement in MNCH can target these mechanisms in order to improve both health and gender equality. The main recommendation emerging from the thesis is presented in the form of the theory of change. This theory of change indicates key mechanisms, predominantly at the individual and interpersonal level, through which interventions to influence men’s engagement in MNCH can lead to improved health and gender equality outcomes. It is hoped that policymakers and programmers will use, contextualise, and adapt the theory of change developed through this thesis, in order to support the design, delivery and monitoring of interventions that engage effectively with men to achieve optimal benefits. Thesis findings also highlight the critical importance of a gender-transformative approach to engaging with men for MNCH. Consequently, a strong recommendation emerging from the thesis is that interventions designed to influence men’s engagement in MNCH should incorporate locally relevant gender-transformative messages and approaches, and monitor the extent to which established and emerging local norms around fatherhood, motherhood, coparenting and caregiving enable men’s positive involvement in MNCH. Work completed for this thesis has also highlighted ways in which health systems can constrain men’s ability to engage in MNCH. Health policy and health services stakeholders should implement supply side interventions to enable men’s engagement in MNCH services and other health services, using a health system strengthening approach to ensure that these changes do not place an unacceptable strain on existing services. There is also the opportunity for health and social services to better support critical outcomes that optimise the benefits of men’s engagement in MNCH. Specifically, services that reach one or both parents during the perinatal period should provide screening and support for both paternal and maternal health, and should also incorporate some degree of support for positive coparent and father-child relationships where this can be done without compromising service quality or safety. Finally, to avoid causing harm, policies and programs designed to influence men’s engagement in MNCH should respond to the reality of diverse families, women, and men, by consulting with diverse stakeholders, using inclusive messages and approaches, and ensuring that intended outcomes are relevant and acceptable to the target population. Future research will be needed to further strengthen and consolidate the evidence base in this rapidly evolving field, by assessing the outcomes and processes described in the proposed theory of change, including maternal and paternal mental health. Implementation research is also required to develop practical guidance for designing interventions and maintaining implementation fidelity, particularly regarding gender-transformative messages and delivery strategies

How do women, men, and health providers perceive interventions to influence men's engagement in maternal and newborn health? A qualitative evidence synthesis

Globally, there is growing awareness of the important contributions men can make as key stakeholders in maternal and newborn health (MNH), and increased investment in interventions designed to influence men's engagement to improve MNH outcomes. Interventions typically target men, women, couples or health providers, yet how these stakeholders perceive and experience interventions is not well understood and the fact that women may experience these interventions as disempowering has been identified as a major concern. This review aims to synthesise how women, men, and providers perceive and experience interventions designed to influence men's engagement in MNH, in order to identify perceived benefits and risks of participating in interventions, and other key factors affecting uptake of and adherence to interventions. We conducted a qualitative evidence synthesis based on a systematic search of the literature, analysing a purposive sample of 66 out of 144 included studies to enable rich synthesis. Women, men and providers report that interventions enable more and better care for women, newborns and men, and strengthen family relationships between the newborn, father and mother. At the same time, stakeholders report that poorly designed or implemented interventions carry risks of harm, including constraining some women's access to MNH services and compounding negative impacts of existing gender inequalities. Limited health system capacity to deliver men-friendly MNH services, and pervasive gender inequality, can limit the accessibility and acceptability of interventions. Sociodemographic factors, household needs, and peer networks can influence how men choose to support MNH, and may affect demand for and adherence to interventions. Overall, perceived benefits of interventions designed to influence men's engagement in MNH are compelling, reported risks of harm are likely manageable through careful implementation, and there is clear evidence of demand from women and men, and some providers, for increased opportunities and support for men to engage in MNH

A mortality review of adult inpatients with tuberculosis in Mendi, Papua New Guinea

Setting: Mendi Provincial Hospital, Southern Highlands Province, Papua New Guinea (PNG). Background: PNG is a high burden country for tuberculosis (TB) and TB-human immunodeficiency virus (HIV). TB is the second most common cause of death in PNG. Objective: To identify the number of adult inpatients with TB who died between 1 January 2015 and 30 August 2017; describe these patients' characteristics and identify contributing factors that could be modified. Design: This was a retrospective case series review. Results: Among 905 inpatients with TB during the study period, there were 90 deaths. The patients who died were older than those who survived (median age 40 years vs. 32 years, P = 0.011). The majority of patients who died lived less than 3 hours from the hospital (71%), were diagnosed after admission (79%) and were clinically diagnosed (77%). HIV status was not known in 50% of the deaths. Of patients with a known status, 27% (12/45) were HIV-positive. The median symptom duration prior to presentation was 28 days, with females presenting later than males (84 vs. 28 days, P = 0.008). Conclusion: This study highlights areas where community and hospital-based management of TB could be improved to potentially reduce TB mortality, including earlier detection and treatment, improved bacteriological diagnosis and increased HIV testing

Factors that influence the uptake of postnatal care from the perspective of fathers, partners and other family members: a qualitative evidence synthesis

Background Postnatal care (PNC) is a key component of maternity provision and presents opportunities for healthcare providers to optimise the health and well-being of women and newborns. However, PNC is often undervalued by parents, family members and healthcare providers. As part of a larger qualitative review exploring the factors that influence PNC uptake by relevant stakeholders, we examined a subset of studies highlighting the views of fathers, partners and family members of postpartum women. Methods We undertook a qualitative evidence synthesis using a framework synthesis approach. We searched multiple databases and included studies with extractable qualitative data focusing on PNC utilisation. We identified and labelled a subset of articles reflecting the views of fathers, partners and other family members. Data abstraction and quality assessment were carried out using a bespoke data extraction form and established quality assessment tools. The framework was developed a priori based on previous research on the topic and adapted accordingly. Findings were assessed for confidence using the GRADE-CERQual approach and are presented by country income group. Results Of 12 678 papers identified from the original search, 109 were tagged as ‘family members views’ and, of these, 30 were eligible for this review. Twenty-nine incorporated fathers’ views, 7 included the views of grandmothers or mothers-in-law, 4 incorporated other family member views and 1 included comothers. Four themes emerged: access and availability; adapting to fatherhood; sociocultural influences and experiences of care. These findings highlight the significant role played by fathers and family members on the uptake of PNC by women as well as the distinct concerns and needs of fathers during the early postnatal period. Conclusion To optimise access to postnatal care, health providers should adopt a more inclusive approach incorporating flexible contact opportunities, the availability of more ‘family-friendly’ information and access to psychosocial support services for both parents